Brigadier-General Jean-Robert Bernier, who took over as Surgeon General and Director General of the CAF Health Services Group in July 2012, sat down with FrontLine to discuss priorities and responsibilities. Published in two editions, the first part (2013 issue 4) talked about mental health issues, and this portion sheds light on the complexities of managing such a large and diverse medical organization, which has a unique ratio of challenges compared to civilian medical requirements.

The Medical Services Group of the Canadian Armed Forces (CAF) has been through a decade or more of renewal, reform and enhancement of capabilities. Examples of these changes are the big RX2000 project to rebuild medical services, and additional enhancements since 2006 that resulted from experiences in Afghanistan. The CAF Health Services now uses a digital health informatics system that facilitates connectivity to the military defense computer network and allows clinicians to access the medical records of military members from anywhere. “We’re way ahead,” says Bernier and, as a result, the CAF Health Services is “recognized both nationally and internationally as leaders in lots of areas of military medicine but also areas of primary care, military mental health, trauma management, and rehabilitation.”

Canada was the recent recipient of NATO’s highest award for medical achievement, the Dominique Jean Larrey Award, for the establishment and command of the Multinational Medical Unit at Kandahar Airfield between 2006 to 2009. Among a long list of examples of international recognition, Bernier cites a recent conference organized by the American Psychiatric Association, where the Canadian military’s mental health system was described as the model the US is following. And last year’s national Royal College of Physicians and Surgeons’ simulation competition was won by a CAF team. Back home, he says the Mental Health Commission of Canada looks to the CAF model for its ‘Road to Readiness’ program, which various police groups are also looking at adopting. In October, Princess Anne, the Colonel in Chief for the Medical Services, came to Canada to award a new royal banner honouring the performance and valour of CAF Medical Services in Afghanistan.

Based on these and other accolades, BGen Bernier considers it his responsibility to consolidate and maintain the capabilities that have been so well established. However, he is very aware that “the realities of our responsibilities to contribute to deficit reduction means there are some impacts on the military health services, so I need to consolidate and manage based on the best possible performance measurement, management and research.” He says his number one priority is to utilize objective measures to guide program modifications and policies “to provide the biggest bang for the buck of defense dollar in maintaining all these capabilities, including mental health.”

Maintaining these capabilities combines four components – “training, education, research and people” – in optimal balance. Which leads our discussion to the Director General’s second priority, which is “to increase our readiness for capabilities that the Afghan conflict required us to, relatively, neglect.”

Preparing for combat operations in Afghanistan meant the CF medical organization has spent the last decade primarily training to handle mass casualties while many other capabilities were moved to the backburner – these now need to be restored. Bernier cites the example of CBRN response, which makes sense as anti-terror within Canada moves up the list of national security concerns. “During the Cold War, we were very slick and ready to deal with chemical, biological, radiological [and nuclear] attacks, and we still have superb capabilities in that area; I think we had the best medical countermeasures in the world overall, but as for training and managing mass casualties of that nature, we haven’t had time to exercise that – we need to reestablish that capability.”

Medical technicians unload a simulated patient from an ambulance in a scenario during Exercise Maple Resolve 13 (JOINTEX) in Wainwright, Alberta.

As for humanitarian assistance capabilities, Haiti is widely considered a success story. True, they were able to quickly establish a little 100-bed field hospital after the devastation, “but it took a lot of transport resources and we weren’t really well organized for it,” he admits in retrospect. The Surgeon General is now examining new requirements to support special ops missions with surgical capability. “To handle those,” he says, “we will have to increase our mobility, the lightness, and the speed with which we can deploy surgical and other medical capabilities in support of humanitarian assistance missions and ­special operations missions.”

To that end, the focus of the Medical Services Group is turning toward “trying to modularize with scaleable deployable capabilities so, with the first aircraft that deploys, we actually get a surgical capability on the ground; and both capacity and capability are increased with subsequent aircraft that go in. We’ve now established a mobile surgical resuscitation team that go in very rapidly and can do surgery in the back of an airplane or on a ship, or anywhere, and can deploy with special ops for emergency situations.”

Speed and modularity are clearly seen as the way of the future. “We’ve modularized our advanced medical surgical capability to be able to deploy much more rapidly for humanitarian assistance and other missions where we need to get medical and surgical capability rapidly to support our larger forces.” To do so, the Medical Services Group has been assessing protocols so that larger groups can be deployed to support a task force, or smaller, very light surgical teams can be rapidly deployed to efficiently support the requirements of special operations missions.

Diminishing Resources
On the topic of performance measurement, BGen Bernier asserts that decisions in the medical world, including reducing resources, must be “based on science, based on evidence, and objective measures. We’re pretty good at it, because that’s the medical culture, but we have to do that much more now with resource management – as do all provincial health jurisdictions.”

Its health information system is critical to the measurement and quality improvement processes in the Canadian Forces and, as the only complete health system run by the federal government, it is continually under the assessment microscope. “We have to be able to constantly demonstrate to the auditor general, the chief of review services, and other external observers that we have an excellent system,” notes Bernier. Every few years, external authorities such as Accreditation Canada, assess the quality of care provided by the CAF Health Services Group, “and we’ve just gotten our second accreditation recently.”

Public Works and Government Services Canada (PWGSC) contracted an independent audit firm to examine costs and the use of CAF medical funding and “they found, when comparing apples to apples (how much it costs the military health system to deliver different types of units of health care) that although overall, our per capita medical system costs more than a provincial one, the reason for that is that we have to be able to do things that no provincial system has to do. For instance, no provincial system has to have all its clinicians trained up to go to war and survive hostile fire, chemical, biological, and radiological attacks, tropical medicine, and all the unique aspects of military training and readiness.”

2009 – Ordinary Seaman (OS) Mitchell Stokes and OS Allyson Boutin ­participated in a Search and Rescue Exercise between HMCS Fredericton and the Israeli Navy, off the coast of Israel during a six-month mission to the Arabian Sea, Gulf of Aden and Horn of Africa to conduct counter-piracy and counter terror operations ­alongside NATO and Coalition partners.

Deficit reduction requirements have resulted in personnel reductions in the health services (both regular force and reservists). “Some of that we can deal with,” says BGen Bernier, explaining that there is less demand now that Canada has ended combat operations in Afghanistan. Running the tertiary care component for all of Southern Afghanistan was both a financial and resource burden, and removing that component has alleviated some of the demands on medical services despite the personnel reductions. “But we have to make sure that we not just maintain and consolidate all of the established capabilities, but progress and improve in certain areas where we can – and they’re not mutually exclusive.”

Bernier reiterates that it is important to “consolidate the capabilities that we have established (combat casualty care, trauma, mental health, etc), and increase our readiness for mobility, modularization, and revive our neglected capabilities (such as Arctic, CBRN, major disaster response).”

If the Northwest Passage becomes navigable to the extent that tourists regularly go up there, the Medical Services will have another reason to prepare for long distance evacuation, rapid mobility, and lighter deployability. They will have to be able to project capabilities over great distances to medically stabilize and evacuate victims. Of course, Canada’s military must be prepared for both domestic defense and for expeditions overseas, so the Medical Services is accustomed to such diverse requirements. However, BGen Bernier notes that “we’ve been focusing on requirements for Afghanistan for so long now that we’ve neglected some capabilities. For example, we will have to place a greater focus on the treatment of cold injuries, and all the equipment, training needed to be able to do that.”

Veterans
Acknowledging that a portion of the injured cannot return to military duty, he clarifies that “because our armed forces is a limited size, and Canadian society has limited resources, we can’t retain people who can’t meet the basic requirements of survival in warfare, and so there’s the universality of service principle and there’s a few minimum things that everybody, every cook, clerk, lawyer, doctor has to do to deploy in operations, and if they can’t, then we’re not fulfilling the mandate of the Armed Forces. Some of our occupations are very small, like 10 people, and if three of them are injured and we retain them, that imposes a burden on the remaining seven to do all of the deploys and it’s unfair to them as well, and so the Armed Forces can’t necessarily retain people who can’t do the full job. If we can’t though, after all that effort, if we can’t build them back up to be well enough to go back to their full duty, then we have a tight relationship with Veterans Affairs to have a smooth transition to civilian life, and so there’s all kinds of programs to get people ready, generous programs to provide them with vocational rehabilitation, retraining so that when they do leave the armed forces, when they are released and they come under the provincial health system and Veterans Affairs that we give them everything possible to have them ready to have as smooth a transition as possible to civilian life.”

What is missing from this explanation is a true understanding that for those who are too mentally or physically injured, the reality of transitioning to “civilian life” can be either too painful or non-existent.

The Canadian public is shocked by reports that our wounded soldiers are being “given” medical releases before the 10-year service requirement of their military pension. More than a few reporters have pointed to the incongruity between our lack of support to our broken soldiers and the full pension for MPs after serving only six years. MPs do not sign a contract to give their lives in service to the Queen as necessary. As widely reported this past summer, many long-term MPs will be eligible for $100,000+ pensions for the rest of their lives. Does their job put them at risk for PTSD, for losing limbs or their lives? According to the National Post, spending watchdogs have calculated that Canadian taxpayers contribute more than $25 for every dollar from MPs for their pensions. And these same MPs sit idly by as Canada chisels pensions from our most severely injured soldiers.

Canadians unanimously agree, the CAF should not be washing its hands when a soldier cannot be returned to a war zone (no matter how appealing it looks at budget time). Stop hiding behind pending studies. We must look after them all, now.

Wrap up
“We don’t do this alone,” BGen Bernier wants to clarify. “We have partnerships with every major research organization […] we’re integrated with lots of research partners, with all of the key health authorities and associations, with private associations, with the Royal Canadian Legion (which does great work supporting the health of the troops), all the various medical associations, a lot of uni­versities […] we’re fully integrated with the whole Canadian system and our allies – we’re tightly integrated with everything that can contribute to maximizing military health. We have the wholehearted support of the Canadian health community going out of their way wanting to help support us in caring for the troops.”